TDM Examination sample case F
Get familiar with the multiple-choice and short-menu question types you will see on the TDM Examination.
A 68-year-old woman presents to the emergency department with a 4-day history of fever, productive cough with yellow sputum, and worsening shortness of breath on exertion. She reports no recent travel. She lives in a 2-storey home with her husband.
She has a history of chronic obstructive pulmonary disease and type 2 diabetes. She takes tiotropium daily, salbutamol PRN, and metformin 1000 mg BID.
Her vital signs are as follows:
She appears well. There are crackles and bronchial breath sounds in the right lower lobe. There is no wheezing.
Laboratory results include the following:
An electrocardiogram reveals sinus tachycardia, no ischemic changes, and a QTc of 580 milliseconds (< 460).
Which of the following are the most appropriate medication options to prescribe? Select 2.
Which of the following are important adverse effects of the treatment in question 1? Select 2.
The patient will be discharged with appropriate follow-up. Which of the following recommendations should be made at this time? Select 2.
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In older adults (≥ 65 years) with major comorbidities (e.g., chronic obstructive pulmonary disease [COPD], diabetes mellitus) treatment of community-acquired pneumonia should include antibiotics active against typical organisms (e.g., Streptococcus pneumoniae, Haemophilus influenzae) and atypical organisms (e.g., Mycoplasma pneumoniae, Legionella pneumophila). In this case, the patient has a prolonged QTc, so the most appropriate options are cefuroxime or doxycycline, because each provides adequate coverage while not further prolonging the QT. Azithromycin and levofloxacin should be avoided in the setting of known prolonged QT. Amoxicillin is less dependable against H. influenzae and other typical pathogens in COPD. Neither oseltamivir nor remdesivir is indicated in the absence of features suggestive of influenza or COVID-19, and given the late presentation and lack of efficacy at this time. Meropenem is not warranted here because there is no evidence of a severe infection requiring intravenous antibiotics and critical care.
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Esophagitis and photosensitivity are important adverse effects of doxycycline. Cefuroxime is generally well tolerated. Arrhythmia, fluid retention, hyperglycemia, hyperkalemia, hyponatremia, ototoxicity, and tendon rupture are not expected adverse effects of either of these drugs. Stevens-Johnson syndrome, hepatotoxicity, and renal impairment are rare adverse effects.
May DB. Tetracyclines. UpToDate. Updated January 31, 2025. Accessed January 21, 2026.
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For patients discharged after treatment for community-acquired pneumonia, monitoring for complications is important. They should be advised to complete the full course of prescribed medication and return if complications arise. Resting in bed until symptoms improve is not advised, as early, safe mobilization is preferred. Home isolation and use of an N-95 mask are unnecessary without a transmissible airborne pathogen. Home oxygen requires documented, persistent hypoxemia that meets established criteria, and this has not been demonstrated here. Outpatient pulmonary rehabilitation is valuable for stable chronic obstructive pulmonary disease, but it is not a routine immediate postpneumonia discharge measure. Cough suppressants can interfere with airway clearance and mask clinical deterioration.
File TM Jr. Patient education: Pneumonia in adults (beyond the basics). UpToDate. Updated May 17, 2024. Accessed January 21, 2026.